Modern healthcare construction rarely happens in a vacuum. More often, it unfolds inside fully operational hospitals, where patients are receiving care, clinicians are performing procedures, and even minor environmental disruptions can carry serious consequences. In renovation projects, the boundary between work zones and the rest of the world runs right through the middle of an operating building, with a crew tearing out ceilings on one side and a patient recovering from surgery on the other.
Dust, vibration, changes in airflow, and uncontrolled access points introduced during construction can create pathways for pathogens, increasing the risk of secondary infections. This risk is especially pronounced during renovation work, where decades-old hospital buildings may conceal mold, pathogens, asbestos, or other hazardous materials behind ceilings, walls, and floors. Once disturbed, those materials don’t stay put. They can travel through HVAC systems, catch drafts, and hitch rides on clothing. The margin for error is essentially zero in a delicate environment like an occupied hospital.
Infection Control Risk Assessments (ICRAs) exist to manage exactly this kind of risk. They provide a structured framework for improving facilities without compromising patient safety.
Planning for Protection from the Start
At Barton Malow, ICRA planning begins early during preconstruction, with direct involvement from hospital infection prevention, facilities, safety, and clinical leadership. Together, teams map out the scope of work, identify nearby patient populations, and determine what’s required to isolate construction activity from occupied spaces before work begins.
The American Society for Health Care Engineering (ASHE) ICRA matrix helps guide that conversation, providing a consistent way to evaluate risk levels and define appropriate protections based on the work being done and its proximity to patient care areas. By the time construction starts, infection control measures aren’t determined on the fly; they’re already clearly defined, documented, and built into the project plan.
On Orlando Health projects, my colleague, Barton Malow Project Executive Tyler Donnell, and his team partnered closely with the client and partners to proactively address phasing and constructability challenges. Equally important, the team worked directly with user groups and surgical staff to establish communication channels that supported daily coordination, adherence to surgical windows, and uninterrupted operations. This early alignment ensured construction sequencing, access routes, and containment strategies were planned around patient safety and clinical priorities, while enabling rapid issue resolution when conditions evolved in the field.
“Early ICRA planning is about more than compliance, but about respecting the clinical environment. By engaging infection prevention, facilities, and surgical teams early, we can plan construction around patient care, not the other way around. That coordination allows us to protect patient and staff while delivering complex work safely and efficiently.”
– Barton Malow Project Executive Tyler Donnell
Executing ICRA in High-Risk Environments
In a highly specialized, occupied pediatric facility renovation, Barton Malow is converting existing space into an intraoperative MRI (iMRI) suite with direct access to an operating room, all while patient care continues throughout the surrounding floor. And not just any patient care, either, but care for an extremely sensitive population: immunocompromised children.
Other Barton Malow healthcare renovations are just as complex. One project includes a 20,000 SF patient floor located seven stories up, enclosed by an exterior curtain wall. Another at the Sheltering Arms Institute involves an entire patient floor with utility tie-ins at 30 different locations to an occupied floor below. ICRA containment procedures were established in the patient room beneath each tie-in, work was completed, and the team moved to the next room.
In these settings, infection control measures define how the project operates. Full-height, hard barriers with sealed penetrations isolate the construction zone. Negative air pressure is continuously maintained with HEPA-filtered air machines, so airflow pulls inward rather than pushing construction air out toward patient spaces. Ductwork, returns, and ceilings are carefully sealed to keep particles contained.
Daily Accountability in the Field
ICRA compliance doesn’t stop once barriers are in place. Pressure differentials are regularly monitored with manometers to confirm that negative pressure is maintained. Hospital and construction teams inspect barrier integrity, cleanliness, and airflow performance on an ongoing basis, catching issues before they affect patient care. In highly regulated healthcare environments, keeping detailed documentation is also essential to support reviews by external accreditation agencies, such as the Joint Commission.
Logistics are equally critical. Material deliveries, debris removal, and team member circulation are carefully coordinated to keep interaction with patients and staff to a minimum. When hard barriers aren’t practical, during utility tie-ins, for instance, portable containment units fill the gap.
Every Barton Malow team member and trade partner working within these environments receives infection control training specific to the project. The expectation is that everyone on site, regardless of trade or scope, understands the rules and follows them consistently.
Building with Confidence in Active Care Settings
In active healthcare construction settings, ICRA serves as a living framework that evolves alongside the work. When challenges arise, our teams must adapt without loosening their grip on the controls that matter most. That requires not just good planning upfront, but also a culture on the jobsite that treats patient safety as the job, not an add-on.
Through early planning, continuous monitoring, and close collaboration with hospital partners, Barton Malow delivers complex construction within active healthcare facilities—protecting patients, supporting caregivers, and allowing critical care operations to continue without disruption.
About the Author: Willie Harris, DBIA, LEED AP, is the Office Director for Barton Malow’s Richmond, Virginia office and an experienced construction leader. With expertise spanning client relationships, preconstruction, project delivery, and team development, Willie helps drive the performance and growth of Barton Malow’s operations across Virginia.
Frequently Asked Questions
An ICRA is a structured framework used to evaluate and manage infection risks during construction or renovation work in occupied healthcare facilities. It identifies potential hazards — like dust, airflow disruption, and exposure to hidden pathogens — and defines the protective measures needed before work begins.
ICRA planning typically involves a cross-functional team including hospital infection prevention specialists, facilities managers, safety officers, clinical leadership, and the construction team. Early collaboration between all parties ensures that controls are defined and documented before work starts, not figured out on the fly.
Common isolation measures include full-height hard barriers with sealed penetrations, negative air pressure maintained by HEPA-filtered air machines, and carefully sealed ductwork, returns, and ceilings. The goal is to ensure airflow always pulls inward toward the work zone rather than pushing construction air into patient spaces.
Negative air pressure means the air pressure inside the construction zone is lower than in the surrounding hospital areas. This causes air to flow into the work zone rather than out of it, preventing dust, particles, and potential pathogens from escaping into patient care areas.
Compliance is an ongoing process. Pressure differentials are regularly checked using manometers, and both hospital and construction teams conduct routine inspections of barrier integrity, cleanliness, and airflow. Detailed documentation is also maintained to support reviews by accreditation agencies like the Joint Commission.
Older hospital buildings may conceal hazardous materials such as mold, asbestos, or entrenched pathogens behind walls, ceilings, and floors. When those materials are disturbed during renovation, they can travel through HVAC systems or on workers’ clothing. This makes thorough pre-construction assessment and containment planning especially critical.
Every team member and trade partner working in an active healthcare environment receives infection control training specific to that project. The expectation is that all workers — regardless of trade — understand and consistently follow the site’s ICRA protocols.
